Journal of Clinical Anesthesia (2011) 23, 35–41

Original contribution

Ergonomic task analysis of ultrasound-guided femoral nerve

block: a pilot study☆
Muhammad Ajmal MBBS, DA (Resident in Anesthesia)a,⁎,
Susan Power MBChB, MFOMI (Resident in Occupational Health Medicine)b ,
Tim Smith (Consultant Ergonomist)c ,
George D. Shorten FFARCSI, PhD (Professor of Anesthesia)a
a
Department of Anesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Wilton, Cork, Ireland
b
Department of Occupational Health Medicine, Cork University Hospital, Wilton, Cork, Ireland
c
Employment Health Limited, Blackrock, Cork, Ireland

Received 6 August 2009; revised 6 May 2010; accepted 16 June 2010

Keywords:
Anesthesiologists'
performance;
Ergonomic task analysis;
Peripheral nerve block;
Ultrasound-guided
femoral nerve block
Abstract
Study Objective: To apply ergonomic task analysis to the performance of ultrasound-guided
(US-guided) femoral nerve block (FNB) in an acute hospital setting.
Design: Pilot prospective observational study.
Setting: Orthopedic operating room of a regional trauma hospital.
Subjects: 15 anesthesiologists of various levels of experience in US-guided FNB (estimated minimum
experience b 10 procedures; maximum about 50 procedures, and from basic trainees to consultants); and
15 patients (5 men and 10 women), aged 77 ± 15 (mean ± SD yrs) years.
Measurements/Observations: A data capture “tool”, which was modified from one previously
developed for ergonomic study of spinal anesthesia, was studied. Patient, operator, and heterogeneous
environmental factors related to ergonomic performance of US-guided FNB were identified. The
observation period started immediately before commencement of positioning the patient and ended on
completion of perineural injection. Data were acquired using direct observations, photography, and
application of a questionnaire.
Main Results: The quality of ergonomic performance was generally suboptimal and varied greatly
among operators. Eight (experience b 10 procedures) of 15 operators excessively rotated their head,
neck, and/or back to visualize the image on the ultrasound machine. Eight operators (experience b 10
procedures) performed the procedure with excessive thoracolumbar flexion.
Conclusion: Performance of US-guided FNB presents ergonomic challenges and was suboptimal during
most of the procedures observed. Formal training in US-guided peripheral nerve blockade should
include reference to ergonomic factors.
© 2011 Elsevier Inc. All rights reserved.

☆
1. Introduction
Statement of interest: The authors have no conflicts of interest to
disclose in this study.
⁎ Corresponding author. Tel.: +353 86 023 1261 (mobile). Ergonomics is the science of physical interaction between
E-mail address: ajmal_c@hotmail.com (M. Ajmal). humans and their working environment, while “human

0952-8180/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2010.06.006
36
factors engineering” is the study of underlying cognitive
elements responsible for such interaction. The application of
ergonomic strategies requires the study of body mechanics,
the nature of the work performed, and the individual
performance of a worker. When successfully applied, such
strategies may optimize system performance while maximiz-
ing human well-being and operational effectiveness. Ergo-
nomics also embraces a range of issues relevant to equipment
or systems design and training: motion and strength
capabilities (biomechanics), sensory-motor capabilities—
vision, hearing, haptics (force and touch), and dexterity [1].
Due to advances in medical knowledge and biomedical
technology and the expectations of the society, medical
professionals currently work in complex and demanding
environments. One example of this is the work of an
anesthetist/anesthesiologist in a modern operating room
(OR). Although ultrasound-guided (US-guided) peripheral
nerve blockade is now widely practiced and its use is likely
to increase further, most ORs have not been modified
according to the requirements of US-guided peripheral nerve
blockade. As the operators performing this technique
respond to visual, haptic, and auditory input from multiple
sources, the procedure presents an ergonomic and clinical
challenge, especially in an environment that has not been
designed or prepared for these procedures. There is growing
recognition of the relevance of ergonomics to surgery and
anesthesia practice [2,3]. To date, ergonomics is not taught in
most anesthesiology training programs although the potential
benefits of such teaching have been recognized [4-6].
Evidence exists that even simple and short surgical
procedures carry occupational hazards if ergonomic princi-
ples are overlooked [7]. The first step in identifying a need to
change practice or training was to perform a preliminary
observational pilot study of anesthesiologists' ergonomic
performance in a “real world” clinical setting. The principal
objective of this pilot study was to apply ergonomic task
analysis to performance of US-guided femoral nerve block
(FNB) in a busy acute hospital setting [8].
2. Materials and methods
With approval of the Clinical Research Ethics Committee
of the Cork Teaching Hospitals, Cork, Ireland, and having
obtained written, informed consent from each participating
subject (patient and anesthesiologist), a pilot prospective
observational study of anesthesiologist's ergonomic beha-
vior while performing US-guided FNB was undertaken in a
busy orthopedic OR using ergonomic task analysis [9]. In
this setting, US-guided FNB is frequently performed on
patients undergoing lower limb trauma surgery of hip, knee,
or femur as an adjunct to general anesthesia, or to facilitate
positioning for spinal anesthesia.
A data capture “tool”, which was developed to study the
ergonomics of spinal anesthesia, was modified based on a
M. Ajmal et al.
series of multidisciplinary (anesthesiologists, occupational
health physician, and ergonomist) discussions [10]. Adjust-
ments included parameters and ratios to indicate quality of
ergonomic performance of US-guided FNB, eg, the
operator's degree of rotational movement to visualize the
image on the US screen.
The preliminary version of this tool was piloted on three
procedures; the resulting minor modifications led to the final
version. For instance, in the preliminary version of the tool,
the height of the US screen was measured from the ground to
the top edge of the screen; in the final version, this height
extended to the vertical midpoint of the US screen.
Development of the tool was guided by applicable basic
ergonomic principles [1].
The areas of interest were patient, operator, and
environmental factors of ergonomic relevance. For instance,
patient factors included height of skin puncture point and
distance of skin puncture point from the (proximal) edge of
the OR table. Operator factors included the position of the
operator relative to the US machine, the operator's (back)
posture, and his/her rotational head, neck, or back move-
ments during the procedure. Factors other than patient and
operator were included in a heterogeneous group of
environmental factors, eg, light intensity and position of a
dedicated assistant relative to the operator during the
procedure. The final version of the tool was then applied to
15 procedures to acquire qualitative and quantitative data.
The data capture tool is shown in Appendix A.
Fifteen anesthesiologists (operators) at different levels of
training and variable previous experience in US-guided FNB
and 15 patients undergoing lower limb trauma surgery of hip,
femur, or knee, were recruited for this study. Recruitment
took place between March and June, 2009. Recruitment was
intermittent, depending on both patient and anesthesiologist
consents and the availability of a single dedicated investi-
gator with responsibility for real-time data collection.
Obesity (BMI N 30 kg/m2), anticoagulation (INR N 1.2),
previous surgery (eg, inguinal herniorraphy), or any
lesion/deformity in the area (eg, cyst, infection, or lipoma
of the inguinal region) were patient exclusion criteria.
Anesthesiologists were directly observed performing
US-guided FNB in the orthopedic trauma OR. Patients also
were directly observed for the presence of distress before, or
on positioning for, the procedure. The blocks were
performed while patients were on the bed or trolley used to
transport them. There were no standardization of set-up other
than the US machine (M-Turbo 6 – 13 MHZ; Sonosite, Inc.,
Bothell, WA, USA) and block needles (Stimuplex A 0.8 × 50
mm; B. Braun, Melsungen, Germany) used, and the nature of
available assistance was similar in all the procedures. The
observation period started immediately before commence-
ment of patient positioning and ended on completion of
perineural injection of the local anesthetic.
Data were acquired using direct observation, photographs
taken during the procedure, and application of a question-
naire that was distributed to operators at the end of each
Ergonomics and US-guided femoral nerve block
procedure [11-14]. Heights and distances were measured
using a measuring tape. Angles were estimated by direct
observation and assessment of photographs [15]. Success of
the block was assessed by comparing verbal rating pain
scores (VRS) on passive movements immediately before and
10 minutes after the procedure. A questionnaire was used to
ascertain the experience, handedness, height, preference for
holding the block needle in dominant or non-dominant hand,
and intent in performing the block on a patient trolley/bed or
OR table (Appendix B).
3. Results
Fifteen participating anesthesiologists, 13 men and two
women, were directly observed performing US-guided
FNB. Eleven anesthesiologists previously had performed
between 5 and 10 US-guided FNB procedures; three
anesthesiologists, between 15 and 20 procedures; and one
anesthesiologist had previously performed approximately 50
US-guided peripheral nerve blocks. Thirteen of the
participating anesthesiologists were right-handed and two
were left-handed. One block was performed in the
anesthesia procedure room and the other 14 blocks, in the
orthopedic trauma OR. Of the recruited 15 patients, 5 were
men and 10 were women, aged 77 ± 15 (mean ± SD yrs)
years. Of the 15 blocks performed, 6 were on right femoral
nerve and 9 were on the left femoral nerve.
3.1. Patient factors
Among the 15 participating patients, hip, knee, and femur
surgeries were performed in 10, 4, and one patient,
respectively. No patient was in distress before positioning,
and one patient was in mild to moderate distress on
positioning for US-guided FNB. In one procedure, no
antiseptic solution was used to prepare the skin of the patient.
The height of the surface of the OR table (bed/trolley or OR
table) on which patients were lying during the procedure was
79 ± 8.7 (63-94) cm [mean ± SD (range) cm]. The height of
needle insertion was 88.7 ± 8.7 (71-104) cm [mean ± SD
(range) cm]. The horizontal distance of the skin puncture
point from the vertical plane containing the edge of the OR
table on the procedure side was 30 ± 11 (8-41) cm [mean ±
SD (range) cm].
3.2. Operator factors
Of the 15 participants, two were unsuccessful in
localizing the femoral nerve on ultrasonography. One such
procedure was completed by a more experienced person
(with approximately 20 US-guided FNBs vs. b 10 FNBs),
and the same operator converted the other procedure to a
fascia iliaca block. Of the 13 procedures completed by the
initial operators, all were successful as assessed by reduction
37
in pain score applying a VRS 10 minutes later. Intensity of
pain, which was severe on passive movement of the injured
limb before the block, was reduced to a moderate degree after
the block. During only one procedure did the anesthesiol-
ogist palpate the femoral artery before applying the US probe
to localize the femoral nerve. Two anesthesiologists
performed the procedure in the sitting position and 13 did
so in the standing position. Anesthesiologists positioned the
US machine such that, as they began the procedure, the
sonographic screen was directly in front in 6 procedures,
slightly behind to the right in another 6 procedures, and
slightly behind to the left in the remaining three procedures.
The ratio of height (measured sitting or standing) of
operator and height at which skin puncture was performed
was 1.91 ± 0.23 (1.55 – 2.49) [mean ± SD (range)]. The
ratio of height of the operator to the height of the center of
the US screen was 1.5 ± 0.1 (1.23 – 1.63) [mean ± SD
(range)]. The ratio of the height of the operator's dominant
shoulder tip in neutral to that during the procedure was
1.06 ± 0.11 (1 – 1.35) [mean ± SD (range)].
Due to positioning of the US machine relative to the
operator, 9 operators needed to rotate their head, neck,
and/or back markedly so as to visualize the image on the US
machine (ie, rotational movement was estimated N 90° in 6
procedures and ≤ 60°, but N 45° in three procedures).
Regardless of the side that they used to perform the
procedure, three anesthesiologists held the US probe in their
dominant hand and the block needle in their non-dominant
hand, while the other 12 held the US probe in their non-
dominant hand and the US probe in their dominant hand.
The anesthesiologists positioned themselves at the side of
patients such that their neutral forward line of vision was
parallel to the longitudinal axis of patients directed caudad,
cephalad, and at right angles to the longitudinal direction in
one, 9, and 5 procedures, respectively. Seven operators
(with experience b 10 procedures) performed the procedure
with excessive thoracolumbar flexion (flexion about 90° in
one procedure and about 45° in 6 procedures). Ten
operators performed with significant (about 30°) lateral tilt
of their shoulders.
Data obtained from the questionnaire showed that all the
right-handed operators preferred to hold the block needle in
their dominant hand because it facilitated the subtle
movements required for needling. Left-handed operators
replied that they could perform these movements equally
well with either hand. Other operator-related parameters are
summarized in Table 1; performance comparison of
experienced versus inexperienced operators is shown in
Table 2.
3.3. Environmental factor
During all 15 procedures, the block was performed with
the patient on the bed or trolley used for transport to the OR.
The intent (expressed) was to minimize discomfort and pain
to patients being transferred to the OR table. In 8 patients, an
38 M. Ajmal et al.

Table 1 Operator factors obstacles in their vicinity (eg, OR table attachments, image
Experience of participating operators 2/4/7/2 intensifier). All anesthesiologists had dedicated nursing
(n = 15) (Consultant / assistance available. Six assistants positioned themselves to
Senior registrar / the right side of the operators, and 9 were situated in front on
Specialist registrar / the opposite side of the operators.
Basic trainee)
Natural height of operators (cm) 174.5 ± 8.3 (160 – 195)
Height of operators for 168.7 ± 11.3 (138 – 183)
procedure (cm) a 4. Discussion
Height of operators' shoulder tip 157 ± 11.5 (126 – 171)
in neutral (cm) b Our observations indicate that performance of US-guided
Height of operators' shoulder tip 148.8 ± 14.7 (122 – 171)
FNB in the setting described is usually ergonomically
during procedure (cm) b
suboptimal. Operators assumed uncomfortable and unstable
Height of ultrasound machine (cm) c 112 ± 0
positions and body postures presumably as a result of the
Data are means ± SD (ranges) or numbers of anesthesiologists/operators. complex interaction among three simultaneous physical
a
Height measured in the sitting or standing position.
b
Height measured on the side on which the block needle was held. tasks: probe manipulation, needle advancement, and visuali-
c
Height of center of ultrasound screen. zation of the US screen. Lack of attention to the positioning
of items of interest (US machine, patient, assistant, and
instrument tray) and the space available were other
contributing factors. The most common suboptimal posture
extra-inguinal part of the leg was unnecessarily exposed to was an excessive rotational movement of the head and neck
an ambient room temperature of 18 ± 0.2 °C (17.5 – 18.5 °C) (to visualize the image on the US screen) and marked flexion
[mean ± SD (range) °C] during the procedure due to the size of the thoracolumbar spines. Such inconvenient body
of the aperture in the draping sheet available for the postures and the associated rotational movements were
procedure. The antiseptic solution and gel used for the important deviations from optimal ergonomic performance.
procedure were at ambient room temperature. No anesthe- In the small sample of anesthesiologists studied, experi-
siologist had a comprehensive (all-in-one) procedure kit enced operators appeared to perform better in terms of
available for the procedure. Four of 15 anesthesiologists ergonomics (although the data acquired were insufficient to
were positioned such that the monitor screen (Datex-Ohmeda show this finding definitively). Experienced anesthesiolo-
AS/3; Datex-Ohmeda, Inc., Madison, WI, USA) showing gists tended to position the US screen in front and they
noninvasive blood pressure, oxygen saturation via pulse performed the procedure with neutral and erect body posture,
oximetry, and electrocardiography, was not visible to them with minimal rotational movement of the cervical and/or
during the procedure. During one procedure, the assistant, thoracolumbar spine. Inexperienced anesthesiologists posi-
who was positioned to the right side of the operator at his tioned the US screen slightly behind and to one side of their
request to inject local anesthetic solution, partially obstructed body trunk and performed the procedure with significant
the operator's view of the image on the US screen. None of thoracolumbar flexion and excessive rotational movement of
the operators used a dedicated OR light during the procedure. the cervical and/or thoracolumbar spine.
Three operators performed the procedure with all the lights in Trainees are offered little formal guidance regarding
the OR turned off. The movements of two operators were appropriate body postures for practical procedures. Muscu-
markedly impeded during the procedure due to physical loskeletal disorders are a significant occupational hazard in

Table 2 Comparison of ergonomic parameters between experienced and novice operators

Parameter Experienced operators Novice operators
(N 10 procedures) (b 10 procedures)
(n = 4) (n = 11)
Ratio between shoulder heights in neutral 1 ± 0 (1) 1.12 ± 0.15 (1-1.34)
and during procedure a
Marked lateral shoulder tilt (approx. 30°) 50% (2/4) 54% (6/11)
In-front positioning of ultrasound machine 100% (4/4) 27% (3/11)
Marked thoracolumbar flexion (≥ 45°) 0% (0/4) 64% (7/11)
Marked rotational movements of 0% (0/4) 82% (9/11)
cervical spine (≥ 45°)
Data are means ± SD (ranges) or numbers of anesthesiologists/operators.
a
Height measured in the sitting or standing position.
Ergonomics and US-guided femoral nerve block
conventional medical practice [16,17]; block performance
does not represent an occupational hazard to most
anesthesiologists. However, such hazards may apply to
those with preexisting back or neck conditions or to those
who perform many nerve blocks. The more common
implication of ergonomic under-performance of a nerve
block may be on block success or efficiency. In this pilot
study, the majority of procedures performed by trainee
anesthesiologists were successful.
There are very little published data on ergonomics
applied to anesthetic procedures and none that examine
patient, operator, and environmental factors (and their
interaction) simultaneously. An earlier study by this group
indicated a clear ergonomic underperformance by operators
of all levels of experience (ie, lifetime spinal anesthesia
experience range of 10 to 150 or more procedures) in “real
world” clinical practice [10].
Walker [18] and Matthews et al. [19] examined the
postural behavior of anesthesiologists in a simulated
environment. We performed this study in daily routine
environments to evaluate “real world” ergonomic problems
of anesthesia practitioners [20]. We agree with the above-
mentioned investigators about the importance of formal
instruction to novice anesthesiologists regarding appropriate
body postures during performance of anesthetic procedures.
Provision of appropriate “set up” is as important as formal
instruction to ensure the use of appropriate body postures
by the novice providers. A multidisciplinary team of experts
(anesthesiologists, occupational health physician, and
ergonomist) participated both in the design of the
assessment tool and interpretation of these data. Assess-
ments using photographs reduced observer bias and enabled
Appendix A. Data capture tool for prospective observational study titled “An Ergonomic Task
Analysis of Ultrasond-guided Femoral Nerve Block (USgFNB)”
Demographic sheet
Case # ___________________________________________
Date & time _______________________________________
Patient ___________________________________________
Patient age & gender ________________________________
Patient medical record # ______________________________
Surgical procedure ___________________________________
Anaesthetist’s grade of employment _____________________
( ) consultant ( ) junior consultant
( ) specialist trainee ( ) basic trainee
Experience of anaesthetist? (estimated previous USgFNB procedures performed)__________________________________
39
examination of the role of patient, operator, and environ-
mental factors in detail that was impossible by real-time
observation [15].
This pilot study has certain limitations. For assessment
parameters, we depended largely on the general ergonomic
principles applicable to the practice of medicine and surgery
[1]. Participating anesthesiologists were aware of the
purpose of the study and might have altered their behavior
as a result. Angles of rotation and angles of vision were not
measured but estimated either in real-time or from
photographs. With the pilot study, our intention was to
determine if gross deviations from best practice were
present or not, rather than to quantify them. The small
sample size precluded application of inferential statistics for
the purpose of comparison between operators of different
levels of experience.
Our findings indicate that US-guided FNB by inexperi-
enced practitioners is usually performed (at least in the setting
described) without application of basic ergonomic principles.
Acknowledgment
The authors extend their thanks to the nurses: Paula
Fleming, Esther Keame, Gilish O'Shea; porters: Patrick
McCarthy, Frank O'Donovan, Sean Hennessy, Dennis Moss,
Finbar Buckley, Kevin O'Flynn, and Jason Sexton; and
orthopaedic surgeons: Dr. Mitra A., Dr. M. Maqbool
working in Operating Theatre 2 at Cork University Hospital,
Ireland, and the patients who participated, for their help and
cooperation in conducting this study.
40 M. Ajmal et al.

Patient factors

Factor/Parameter Observation/Measurement
Side of femoral nerve blocked ( ) Right ( )Left
Vertical height of operating table /trolley (cm)?
Vertical height of skin puncture (cm)?
Distance of skin puncture from edge of table/trolley (cm)?
Area exposed? ( ) Inguinal ( ) Inguinal and extra-inguinal
Patient in distress? ( ) At rest ( ) On positioning

Operator factors

Factor /Parameter Observation / Measurement

Handedness of operator? ( ) Right ( ) Left
Height of operator (cm)?
Position of operator? ( ) Sitting ( ) Standing
Hand in which ultrasound probe was held? ( ) Right ( ) Left
Hand in which block needle was held? ( ) Right ( ) Left
Vertical height of operators’ shoulder tip in neutral on the side in
which block needle was held (cm)?
Height of operators’ stool (cm)
Posture of operators’ shoulder during procedure? () Neutral ( ) Tilted laterally
Posture of operators’ back during procedure? () Neutral ( ) Flexed about 90° ( ) Flexed about 45°
Rotation of head, neck, and back () None ( ) N 45° ( ) N 90°
Position of operator relative to patient? () Face to face ( ) Face to trunk ( ) Face to leg
Placement of ultrasound machine relative to operator? () In front ( ) Behind on right ( ) Behind on left

Environmental factors

Factor / Parameter Observation/Measurement

Where was block given? ( ) Patient bed / trolley
( ) Operating table
At which location of operating suit block was given? ( ) Anaesthesia room
( ) Operating room
Assistance available from another anaesthetist? ( ) Yes ( ) No
Dedicated nursing assistance? ( ) Yes ( ) No
Position of dedicated assistant relative to operator? ( ) Front ( ) Right side
( ) Left side
Ambient temperature (°C)
Temperature of antiseptic solution used? ( ) Ambient ( ) Special
Temperature of gel used for ultrasound? ( ) Ambient ( ) Special
Use of dedicated light? ( ) Yes ( ) No
Was compact procedure kit available? ( ) Yes ( ) No
Was operator impeded due to obstacles? ( ) Yes ( ) No
Was patient monitor screen (ECG, SpO2, and NIBP) visible to operator during procedure? ( ) Yes ( ) No
Were general lights turned off during procedure? ( ) Yes ( ) No
Height of center of ultrasound screen (cm)?
ECG=electrocardiography, SpO2=oxygen saturation as measured by pulse oximetry, NIBP=noninvasive blood pressure.
Ergonomics and US-guided femoral nerve block
Appendix B. Questionnaire to operators for observational study “An Ergonomic Task Analysis of
Ultrasound-Guided Femoral Nerve Block (USgFNB)”
Name______________________________________________________
Designation ( ) Consultant ( ) Senior registrar
( ) Specialist registrar ( ) Basic trainee
Experience (estimate of life-time USgFNB performed )______________________________________________________
Height (cm) _________________________________________________
Handedness ________ ( ) Right _______ ( ) Left_____
Please answer the following question by selecting appropriate response or by giving explanation:
Q-1- In which hand do you prefer to hold block needle to perform USgFNB?
( ) Right ( ) Left
Q-2- Why do you hold block needle in particular hand?
( ) Routine ( ) Motive
Q-3- Explain your motive in using particular hand to hold block needle?
__________________________________________________________
Q-4- Why did you prefer to perform the block on patient’s trolley/bed instead of operating table?
__________________________________________________________
References
[1] Stone R, McCloy R. Ergonomics in medicine and surgery. BMJ 2004;
328(7448):1115-8.
[2] Berguer R. The application of ergonomics in the work environment of
general surgeons. Rev Environ Health 1997;12:99-106.
[3] Friesdorf W, Konichezky S, Gross-Alltag F, Schwilk B. Ergonomics
applied to anaesthesia record keeping. J Clin Monit Comput 1993;10:
251-9.
[4] Sites BD, Spence BC, Gallagher JD, Wiley CW, Bertrand ML, Blike
GT. Characterizing novice behavior associated with learning ultra-
sound-guided peripheral regional anesthesia. Reg Anesth Pain Med
2007;32:107-15.
[5] Smith AF, Pope C, Goodwin D, Mort M. What defines expertise in
regional anaesthesia? An observational analysis of practice. Br J
Anaesth 2006;97:401-7.
[6] Fletcher GC, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of
non-technical skills in anaesthesia: a review of current literature. Br J
Anaesth 2002;88:418-29.
[7] Esser AC, Koshy JG, Randle HW. Ergonomics in office-based
surgery: a survey-guided observational study. Dermatol Surg 2007;33:
1304-14.
[8] Phipps D, Meakin GH, Beatty PC, Nsoedo C, Parker D. Human factors
in anaesthetic practice: insights from a task analysis. Br J Anaesth
2008;100:333-43.
[9] Baxter GD, Monk AF, Tan K, Dear PR, Newell SJ. Using cognitive
task analysis to facilitate the integration of decision support systems
into the neonatal intensive care unit. Artif Intell Med 2005;35:
243-57.
41
[10] Ajmal M, Power S, Smith T, Shorten GD. An ergonomic task analysis
of spinal anaesthesia. Eur J Anaesthesiol 2009;26:1037-42.
[11] Li G, Buckle P. Current techniques for assessing physical exposure to
work-related musculoskeletal risks, with emphasis on posture-based
methods. Ergonomics 1999;42:674-95.
[12] Leedal JM, Smith AF. Methodological approaches to anaesthetists'
workload in the operating theatre. Br J Anaesth 2005;94:702-9.
[13] Norros L, Klemola UM. Methodological considerations in analysing
anaesthetists' habits of action in clinical situations. Ergonomics 1999;
42:521-30.
[14] David GC. Ergonomic methods for assessing exposure to risk factors
for work-related musculoskeletal disorders. Occup Med 2005;55:190-9.
[15] Weinger MB, Gonzales DC, Slagle J, Syeed M. Video capture of
clinical care to enhance patient safety. Qual Saf Health Care 2004;13:
136-44.
[16] Smith DR, Wei N, Kang L, Wang RS. Musculoskeletal disorders
among professional nurses in mainland China. J Prof Nurs 2004;20:
390-5.
[17] Anghel MD, Lungeanu D, Argesanu V, Comes CA, Talpos CI.
Evidence of the need for ergonomic training of the dentists: there are
costs of a flawed posture and working routine [Abstract]. Eur Cells
Materials 2008;16(Suppl 5):18.
[18] Walker J. Posture used by anaesthetists during laryngoscopy. Br J
Anaesth 2002;89:772-4.
[19] Matthews AJ, Johnson CJ, Goodman NW. Body posture during
simulated tracheal intubation. Anaesthesia 1998;53:331-4.
[20] Zausig YA, Grube C, Boeker-Blum T, et al. Inefficacy of simulator-
based training on anaesthesiologists' non-technical skills. Acta
Anaesthesiol Scand 2009;53:611-9.
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